VANCOUVER — Patricia Reed was diagnosed as a schizophrenic with obsessive-compulsive disorders. She was terrified of death, and she constantly worried about hell. Her husband could not manage with her problems, so three years ago, Ms. Reed was involuntarily committed to Riverview Hospital, a sprawling, century-old asylum for the mentally ill in Coquitlam, a Vancouver suburb.

Riverview was in steep decline, thanks to years of budget cuts and staff reductions. Spread across 244 scenic acres, many of its 94 buildings had been shuttered. More bed closures were coming. It was from this lugubrious environment, on Feb. 9, 2011, that Ms. Reed disappeared.

Five days later, a patient discovered her corpse, face-down in a shallow ditch, next to a walking trail on hospital grounds. The body lay in plain view, completely exposed.

We thought that when we left her in the facility, she was safe

The 59-year-old’s death and the circumstances around it cast a pall over Riverview and raised questions about the standard of care offered to the mentally ill in B.C. Last week, a provincial coroners inquest into Ms. Reed’s death heard how a system meant to protect vulnerable, mentally ill patients had failed miserably.

“We thought that when we left her in the facility, she was safe,” Judy Johnston, Ms. Reed’s younger sister, told the inquest’s five-person jury. Instead, family members feel she was let down by hospital staff and security. They feel they were themselves misled and “victimized” by Riverview, Ms. Johnston said.

The hospital was established in 1904, when treatment of mental illness was rudimentary at best. Patients were usually kept isolated in locked rooms, or crammed into claustrophobic dormitories. By 1960, its resident population had reached 5,000.

As more effective psychotropic medications became available, and beds closed, most Riverview patients were returned to society. By the time Patricia Reed was committed, Riverview had fewer than 300 resident patients.

In her case, she really didn’t want to use the grounds

She was placed under the care of hospital psychiatrist Michael Dowey and was given regular doses of anti-anxiety drugs. Her condition seemed to improve, especially after a course of electroconvulsive therapy. She had permission to leave her unit for two hours each day. Like other patients, she was encouraged to walk about the hospital’s huge campus; staff considered it therapeutic. But she seldom exercised that privilege. She wasn’t one to wander off.

“In her case, she really didn’t want to use the grounds,” Dr. Dowey told the inquest.

Ms. Reed preferred to remain inside her ward, reading her Bible and waiting for her husband to visit, which he did almost every day at lunchtime. On what turned out to be his final trip, Daniel Reed brought his wife a sandwich. But she wasn’t in her ward; she wasn’t to be found.

Testifying at the inquest, hospital staff said four to five Riverview patients vanished every week. They usually left the grounds entirely. Taking an “unexcused absence” was as simple as opening an unlocked door and walking to a bus stop at the foot of the hospital property. Most patients ended up with family members or in downtown Vancouver and returned within a few hours. Some came back with illicit drugs.

I didn’t expect them to run through the forest late at night

When Ms. Reed failed to reappear, local RCMP were contacted. An officer drove around the grounds, calling out to her from a megaphone. He did not leave his police cruiser, the inquest heard. At eight o’clock that night, an RCMP helicopter was directed to fly over the hospital. Infrared-heat detection equipment was deployed, but nothing turned up. Hospital staff took this to mean that Ms. Reed wasn’t on the property. They assumed that she had left the grounds. They were wrong.

Ms. Reed had been missing at least 11 hours before Paladin Security Ltd., the private company contracted to patrol Riverview, was informed. The two security guards on duty were not asked to launch a search. They stuck to their patrol routine, driving around the grounds in cars.

Two more days passed. Ms. Reed’s family was frantic with worry. Judy Johnston called the hospital and complained that staff weren’t doing enough to find her sister. She threatened to notify the news media; this seemed to raised alarms. A supervising nurse told Ms. Johnston that the property had already been “swept,” and that another “extensive” search would be conducted. Every road, building, every trail on the grounds would be examined, the nurse promised. In fact, this was not done. No one checked the trail where Ms. Reed’s body was eventually found, the inquest heard.

Daniel Reed doesn’t know what made his wife decide to walk away from her ward and onto the Riverview grounds. The bigger mystery, he says, is why staff and security didn’t exercise more diligence and look for her. Hospital staff weren’t willing or trained to search for patients. “It wasn’t my responsibility to wander the grounds, looking for people,” Dr. Dowey told the inquest. “We have security for that.”

Paladin didn’t have the manpower or the proper equipment to conduct a proper sweep, a company manager testified. The two duty officers on each shift had enough to do. “I didn’t expect them to run through the forest late at night,” said the Paladin manager, Raymond Chow. “If I was able to bring in extra staff, [the search] probably would have been a lot more effective.”

Mr. Chow claimed that he had recommended bringing over more officers, but the supervising nurse declined.

Ms. Reed’s body lay within 200 metres of Paladin’s hospital operations centre and in view of a two-storey residence for patients. There was no sign of trauma, or any post-mortem interference from animals; coyotes and even bears were known to visit the grounds. A pathologist who conducted her autopsy testified that the patient had likely died of exposure. He could not determine the precise time of death.

Riverview closed this summer. While most remaining patients were moved to much smaller facilities that are scattered about B.C., three mental-health residences and a dozen forensic psychiatric cottages still operate on the grounds. Paladin continues to provide security, and claims to have improved its search procedures and protocols.

But the inquest jury wasn’t satisfied. After hearing evidence last week and putting questions to witnesses, the panel recommended that B.C.’s public heath authorities and its Ministry of Health “ensure that processes are in place for a co-ordinated response to persons that are identified as being on unexcused absence” from mental-health facilities. And involuntary psychiatric patients should be more closely monitored, the jury recommended. “This could involve the use of swipe cards, cameras and/or GPS technology” to determine when a patient leaves a premises, and where she is heading. Had such a simple system been in place last year, it might well have saved a life.